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Media Health Leaders- Gregory A. Freeman, March 26, 2018 Insurance claims for urgent care exploded over a nine-year period, rising much faster than claims for emergency care. Private insurance claim lines for urgent care centers grew 1,725% from 2007 to 2016, more than seven times faster than that of emergency room claims, which grew 229% over the same period. The increases are described in analysis by FAIR Health, a nonprofit organization that focuses on transparency in healthcare costs. The analysis used data from FAIR Health's database of over 25 billion privately billed healthcare claims. The report includes trends and patterns in the places where patients receive healthcare, which the group says have undergone dramatic changes in recent years as alternative places of service—including urgent care centers, retail clinics, telehealth and ambulatory surgery centers (ASCs)—have become more widespread. The urgent care center market has reached 15 billion, according to a report by Kalorama Information. Some of the growth is due to hospital systems starting urgent care centers to reduce the demand at their hospital emergency rooms, aiming to make those areas of their system more profitable, the report notes. Other centers are started by entrepreneurial physicians as a means to expand their income while meeting a market need. The number of clinic locations has similarly risen strongly, standing at over 10,000 locations in 2017, according to the Kalorama report. Kalorama estimates that the average urgent care center in 2016 saw 294 patients per week and about 15,300 patients throughout the year. It predicts patient volume will continue to expand through 2021 to about 300 patients per week. Diagnoses Differ by Location Different places of service are associated with different diagnoses, the FAIR Health report notes. For example, [...]

Modern Healthcare- By Virgil Dickson | March 22, 2018 Lowering documentation standards for a commonly used set of billing codes would lead to better quality of care, doctors told the CMS during a conference call Wednesday. Most physicians bill Medicare for patient visits under a relatively generic set of codes that distinguish the level of complexity and site of care. They are called evaluation and management visit codes. The last significant update to the E/M guidelines was more than 20 years ago. "The agency has heard repeatedly over the years that these documentation guidelines are potentially outdated and need to be revised," Marge Watchorn, deputy director of CMS' Division of Practitioner Services, said during the call which was hosted by the agency to request input from the provider community. The codes were developed with a paper-based system in mind, said Dr. Paul Rudolf, a partner at Arnold & Porter who represents the American Geriatrics Society. Clinicians currently must provide a comprehensive medical history each time they submit a claim. They'd rather document why a patient is receiving care in a specific instance of treatment. "There is now somewhat of a perverse incentive that ordering more tests will meet medical decision-making" standards, said Dr. Thomas Sugarman, an emergency medicine doctor at Sutter Delta Medical Center in California. Requirements around E/M also make it harder to bill for more-intensive office visits for some of the sickest patients. The codes "disincentivize addressing multiple chronic conditions in one visit, which is something we would very much like to do," said Dr. Lindsay Botsford, a family physician at Memorial Hermann Health System in Houston. The CMS first announced its intentions to review E/M guidelines for the 2018 Medicare physician fee schedule rule. Watchorn said [...]

Forbes- Bruce Japsen - MAR 12, 2018 @ 08:00 AM News that Centene is buying a large medical group is the latest sign that health insurers are engaged in a doctor-buying binge to compliment their Medicare Advantage businesses by owning group practices that treat a lot of seniors. In Centene’s case, the health insurer is getting a provider of medical care in Community Medical Group that has 15 health centers throughout the Miami-Dade County area of south Florida. Centene last week described Community Medical as a “leading at-risk primary care provider” that serves more than 70,000 patients including those covered by Medicare Advantage. It’s the kind of deal that insurers are scouting across the country. “There will be more acquisitions of primary care groups,” Bill Frack, a managing director in L.E.K Consulting ’s health care services practice said in an interview. “Sophisticated groups are the best way to manage the cost of care in an effective manner. They have the resources to manage complicated cases in a sophisticated way.” To be sure, health plans are on the hunt to buy doctor practices with the staff, technology, information systems and providers to effectively manage the complex care of elderly Medicare beneficiaries, particularly as value-based care takes hold. Practices that provide effective treatment upfront in the doctor’s office leave more of the premium dollar for an insurance company to profit from or share with the providers. The Centene deal surprised some observers given the insurer is better known for administering Medicaid benefits for states and offering individual coverage under the Affordable Care Act. In buying Community Medical, it will get a provider of medical care that has patients insured by all three forms of insurance: Medicaid, Obamacare [...]

CNN Money- by Paul R. La Monica- March 8, 2018: 12:32 PM ET Get ready for another wave of massive health care deals -- and maybe this time the government will approve them. Health insurer giant Cigna's proposed purchase of pharmacy benefits manager Express Scripts for $67 billion comes just three months after Cigna rival Aetna agreed to be bought by drugstore chain CVS (CVS) for $69 billion. The insurance companies have been forced to find alternative ways to adapt and grow in a rapidly changing health care industry after the Justice Department blocked two massive deals involving four of the five biggest health insurers on antitrust grounds a year ago. Cigna (CI) and Anthem (ANTM) called off their proposed combination in February 2017 -- and rivals Aetna (AET) and Humana (HUM) announced they were ending plans to merge on the same day. UnitedHealth (UNH) is the other major health care insurer. But the Cigna-Express Scripts and CVS-Aetna deals, in theory, have a better chance of getting approved by regulators since they are so-called vertical, as opposed to horizontal, mergers. In plain English, that means the mergers aren't ones where two similar companies are looking to combine and take a competitor out of the market. Instead, they're trying to add a new line of business. Still, the deal between Cigna and Express Scripts (ESRX) is yet another clear sign that the health care industry in America could soon be dominated by just a small handful of giant conglomerates. For example, the pharmacy benefits management industry, which negotiates with the big drug makers to try and get better prices on prescription medications for consumers, is already dominated by Express Scripts, CVS and UnitedHealth. If CVS gets approval to [...]

CNBC -Christina Farr | @chrissyfarr -Updated 11:27 AM ET Tue, 27 Feb 2018 Verily's new hires and partnerships point to a move into health insurance. The company is looking to take on risk for patient populations and sharing in the upside if it can bring down health-care costs, sources tell CNBC. The opportunity is currently in the tens of billions, with the potential to grow into a trillion dollar market. Alphabet's health-care unit Verily is moving ahead with plans in the insurance sector with new hires and partnerships. Three people familiar with the company's plans say Verily, the group formerly known as Google Life Sciences, has been in talks with insurers about jointly bidding for contracts that would involve taking on risk for hundreds of thousands of patients. In 2016, it mulled jointly putting in a proposal with Alphabet-backed insurer Oscar Health to manage care for thousands of low-income Rhode Island residents on Medicaid, one of the sources said, but ultimately decided against it. Now, it is moving ahead with plans to enter into this market, which health insiders often refer to as "population health" or "care management." The population health market is large and growing, but crowded. To enter this space, a vendor like Verily would put forward a proposal to a payor — like the government, an employer or a private insurance company — detailing how it can bring down costs. If a company like Verily can deliver on that, the payor would share some portion of the amount saved. If costs don't come down, it might make no money from that contract. (This is a simplification, and the details vary by contract.) A classic intervention might involve analyzing health data to figure [...]